Provider Demographics
NPI:1033798525
Name:ANGELS AT DIVINE RETREAT LLC
Entity Type:Organization
Organization Name:ANGELS AT DIVINE RETREAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BARKSDALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-257-7136
Mailing Address - Street 1:3065 JEFFERSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-5117
Mailing Address - Country:US
Mailing Address - Phone:478-257-7136
Mailing Address - Fax:478-257-7137
Practice Address - Street 1:3065 JEFFERSONVILLE RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-5117
Practice Address - Country:US
Practice Address - Phone:478-257-7136
Practice Address - Fax:478-257-7137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-03
Last Update Date:2021-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility